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Based on observation and review of facility policy and procedure, it was determined that the facility failed to include a geriatric (geri) chair in their definition of a restraint.

Findings include:

1. On 12/9/14 at 2:10 PM Unit 9 South was toured in the presence of Staff #11 and Staff #87. Patient #8 was observed sitting in a geri chair with a secured table top, outside his/her patient room, across from the nurses' station.

a. Medical Record #8 was reviewed and lacked evidence of a restraint order.

b. Patient #8 was then observed in his/her room in the geri chair, with the secured table top, interacting with a therapist. The geri chair was observed again. Staff #11 confirmed upon interview, that Patient #8 cannot get out of the geri chair on his/her own, and would need staff assistance.

2. Review of the facility's Restraint policy and procedure lacked evidence of a definition of a geri chair with a secured table top as a restraint. Without defining the geri chair as a restraint, the facility's Restraint policy is not consistent with this regulation.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that the use of restraints is in accordance with the order of a physician.

Findings include:

1. On 12/9/14 at 10:15 AM, a review of Medical Record #6 was completed. Documentation in Medical Record #6, on the "Restraint Order Sheet," indicated a physician order for 2-point and 4-point mechanical restraints.

2. On 12/10/14 at 9:15 AM, a review of Medical Record #7 was completed. Documentation in Medical Record #17, on the "Restraint Order Sheet," indicated a physician order for 1-point, 2-point, 3-point, and 4-point mechanical restraints.

3. The physicians orders were not clear and were not specific.

4. The above was confirmed upon interview on 12/10/14 with Staff #6.

Based on document review and staff interview, it was determined that the facility failed to implement its performance improvement plan for all adverse patient events.
Findings include:
1. On 12/11/14 three (3) root cause analyses (RCAs) were reviewed in the presence of Staff #7. RCA #1 was still under review and in process for its quality initiatives. The facility did not implement their monitoring strategies as outlined for RCA #2 and RCA #3.
a. RCA #2 indicated there would be ten (10) audits per week for a two (2) week period. Staff #52 stated upon interview on 12/11/14, that he/she only performed a total of 10 audits over a 10 day period.
b. RCA #3 indicated daily observational audits would be completed. Staff #9 confirmed upon interview on 12/11/14, that daily observational audits were not completed.

Based on observation, document review, and staff interview conducted on 12/11/14, it was determined that the facility failed to ensure implementation of policies and procedures addressing medication administration.

Findings include:

Reference: Mosby, Fifth Edition, page 511, when addressing removal of medication from an ampule, states, "... b. Place small gauze pad around neck of ampule ... Rationale: Placing pad around neck of ampule protects nurse's fingers from trauma as glass tip is broken off. Do not use wet alcohol swab to wrap around top of ampule because alcohol may leak into ampule ... c. Snap neck of ampule quickly and firmly away from hands ..."

1. During a medication pass observation conducted on 12/11/14 at 9:30 AM, Staff #76 was observed snapping the neck of an ampule of Digoxin with gloved hands and then wiping the top of the opening with an alcohol swab prior to withdrawing the medication.

2. Upon interview, Staff #3 stated that the facility has adopted Mosby as their reference source for the preparation of medications.

3. Staff #76 failed to open the ampule of digoxin in accordance with Mosby, Fifth Edition, as referenced above.

4. This finding was confirmed by Staff #68.

Based on document review and staff interview, it was determined that the facility failed to ensure the Facility policy for the preservation of tissue is followed.

Findings include:

Reference: Facility's Department of Laboratory Services Policy #POL-09, states, "Procedure ... 3. The temperature of water baths, heating blocks, refrigerators, freezers, and other temperature-dependent equipment must be recorded daily."

1. On 12/9/14 at 12:10 PM in the Laboratory, Freezer #8's temperature was last recorded on 12/5/14 as indicated on the Temperature Log attached to the Freezer.

a. Staff #4 confirmed that 12/5/14 was the last day that Freezer #8's temperature was recorded.

A. Based on observation, it was determined that the facility failed to ensure that the overall hospital environment is maintained in such a manner that the safety and well-being of patients is assured.

Findings include:

1. On 12/9/14 at 10:35 AM in the presence of Staff #4, the Corridor floor was separated in the Emergency Department, outside the Pediatric Room.

2. On 12/9/14 at 10:40 AM in the presence of Staff #4, the wall was cracked and chipped in Emergency Department Room #3, exposing the gypsum board which can not be properly cleaned.

3. On 12/9/14 at 11:00 AM in the presence of Staff #4, the footrest of the chair in Room #5204 was torn, exposing the inner foam padding which can not be properly cleaned.

4. On 12/9/14 at 12:00 PM in the presence of Staff #4, the florescent light fixture recessed in the ceiling near the door in ICU Room #2022 was flashing.

5. On 12/9/14 at 12:05 PM in the presence of Staff #4, multiple ceiling tiles in ICU Room #2022 were covered with brown stains.

6. On 12/9/14 at 3:00 PM in the presence of Staff #4, the Back Wall of Pre-Op Stations #1 and #2, in the Same Day Surgery Suite, were delaminated and peeling, exposing a surface that can not be properly cleaned.


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B. Based on observation and staff interview conducted on 12/10/14 and 12/11/14, it was determined that the facility failed to ensure that a safe and sanitary hospital environment is maintained for patients, staff, and the general public.

Findings include:

1. During a tour of Operating Room (OR) #4 at 11:57 AM, in the presence of Staff #8 and Staff #43, the following was observed:

a. A patient transfer roller was stored directly on the floor.

i. The patient transfer roller cannot be maintained clean and safe for patient use while stored on the floor.

b. An overfilled, large regulated medical waste sharps container contained several sharp-edged metal wires that were overflowing the container.

i. The metal wires overflowing out of the sharps container pose a potential safety hazard in OR #4.

c. The sterilizer in the sub-sterile area, adjoining OR #4, was observed with rusty build-up in its chamber, and at the base of its door.

d. The above findings were confirmed by Staff #8 and Staff #43.

2. At 11:00 AM, patches of brown, sticky residue and brownish soil, were observed near the control handle of an 'OEC 9800 Plus' [C-arm] that was stored in a storage area across OR #1.

a. This finding was confirmed by Staff #2, Staff #8, Staff #42, and Staff #43.

3. At 11:05 AM, while inspecting the Housekeeping closet, two wet mop-heads were observed stored directly on the floor and one wet mop-head was stored draped over the side of the floor drain wall.

a. The housekeeping closet floor was observed soiled with dirt and brown stains and residue.

b. This finding was confirmed by Staff #2, Staff #8, Staff #42, and Staff #43.

4. During a tour of the OR corridor, in the presence of Staff #2, Staff #8, Staff #42, and Staff #43 at 11:07 AM, a Chick Fracture Reduction Table was observed covered with a layer of dust.

a. This finding was confirmed by Staff #2, Staff #8, Staff #42, and Staff #43.

5. On 12/10/14, during a tour of the connecting bridge to the North Building at 12:15 PM, the floor tiles were broken and missing, and plaster debris littered the floor.

a. This finding was confirmed by Staff #8.

6. On 12/11/14 at 10:35 AM in OR #3, in the presence of Staff #8 and Staff #43, areas of brown stains were observed on the floor directly under the OR table arm-boards.

a. Staff #43 confirmed this finding stating, "These are Betadine stains."

7. On 12/11/14, during a tour of the connecting bridge to the North Building, the cushion of the sofa seat in the patient waiting area was ripped at the corner, exposing the foam underneath.

a. The exposed foam is not a cleanable surface.

b. This finding was confirmed by Staff #2 and Staff #8.

A. Based on observation, review of facility policies and procedures, and staff interview, it was determined that the facility failed to ensure that a sanitary environment to avoid sources and transmission of infections and communicable diseases is provided.
Findings include:
Reference: Facility policy titled "Isolation Precautions" states under "CONTACT PRECAUTIONS, B. GLOVES AND HAND HYGIENE, 1. In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean non-sterile gloves are adequate) when entering the room. ... 3. Remove gloves before leaving the patient's environment and perform hand hygiene. 4. After glove removal and hand hygiene, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments ... C. GOWNS, 1. Wear a gown (a clean non-sterile gown is adequate) when entering the patient's room. 2. Remove the gown and discard before leaving the patient's environment. 3. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments. ..."
1. On 12/11/14 at 11:00 AM, a tour of the 6th Floor Surgical Unit was done in the presence of Staff #22, Staff #61, and Staff #62. Patient #1, in Room #6205, was on Contact Isolation for MDRA [Multi-Drug Resistant Acinetobacter]. A "Contact Isolation" sign was posted outside of the patient's room. Staff #63 was observed standing near the patient bed in Room #6205 without a gown or gloves. Staff #63 then proceeded to exit the room and review a chart at a nearby nurse station, without the benefit of hand washing or applying alcohol based hand gel.
2. These findings were confirmed by Staff #22, Staff #61, and Staff #62.


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B. Based on observation, staff interview, and review of facility policies and procedures conducted on 12/11/14, it was determined that the facility failed to ensure that a sanitary environment is provided, and infection control practices that adhere to nationally recognized infection control guidelines are implemented.

Findings include:

Reference #1: Facility policy titled "Hand Hygiene" states, " ... Procedure: 1. Hand hygiene must be performed before and after patient or patient-care equipment contact ... after removing gloves ..."

Reference #2: CDC Guideline for Hand Hygiene in Health Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force (2002) states on page 32, "Recommendations: 1. Indications for hand washing and hand antisepsis ... (I) Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of patient (J) Decontaminate hands after removing gloves ..."

1. At 10:27 AM, during a procedure in Operating Room (OR) #4, Staff #55 was observed removing a pair of soiled disposable gloves, then donning another pair of gloves without sanitizing his/her hands.

a. This finding was confirmed by Staff #8 and Staff #43.

2. At 12:41 PM, at the end of a surgical procedure in OR #4, Staff #54 was observed removing soiled surgical gloves without sanitizing his/her hands.

a. This finding was confirmed by Staff #43.

Based on medical record review and review of facility policy and procedure, it was determined that the facility failed to implement its policy and procedure for Organ/Tissue Donation Protocol, in one of three patient death records reviewed (Medical Record #11).

Findings include:

Reference: Facility policy and procedure titled 'Organ/Tissue Donation Protocol' states, "... II. TISSUE DONATION A. Candidates for Tissue Donation ... 9. If the deceased is a medically suitable candidate, the nurse will fill out the appropriate information in Section A of the form. The nurse will then notify the Nursing Supervisor of a possible tissue donor. The form will be given to the Nursing Supervisor for completion."

1. On 12/10/14, three patient death records were reviewed. One of the three patients was accepted by the facility's organ procurement organization (OPO) for tissue donation. The 'Notification of --[OPO's name]-- ' form in Medical Record #11 indicated, in Section A, the patient passed on 12/7/14 at 11:35 AM, and the OPO was notified on 12/7/14 at 11:50 AM. The 'Notification of --[OPO's name]-- ' form indicated Patient #11 was determined medically suitable for tissue donation by the OPO.

a. Review of the Emergency Department nursing notes indicated a nursing note on 12/7/14 at 11:50 AM that read "RN [registered nurse] supervisor in ER and aware of expiration."

2. Sections B & C of the 'Notification of --[OPO's name]-- ' form were blank and not completed by the Nursing Supervisor as per the policy referenced above.